Provider Manual BEACON HEALTH STRATEGIES

Transcription

1 BEACON HEALTH STRATEGIES Humana CareSource TM Provider Manual This document contains chapters 1-6 of Beacon s Behavioral Health Policy and Procedure Manual for providers serving Humana CareSource TM. Note that links within the manual have been activated in this revised version. Additionally, all referenced materials are available on this website. Chapters which contain all level-of-care service descriptions and criteria will be posted on eservices; to obtain a copy, please or call eservices April 2013

7 1.1 Beacon/Humana CareSource TM Partnership Humana CareSource TM has partnered with Beacon Health Strategies, LLC to manage the delivery of behavioral health services for its members. Beacon Health Strategies, LLC is a limited liability, managed behavioral health care company. Established in 1996, Beacon s mission is to collaborate with our health plan customers and contracted providers to improve the delivery of behavioral healthcare for the members we serve. Presently, Beacon provides care management services to 7.5 million members through its partnerships with client plans and care management organizations. Most often co-located at the physical location of our plan partners, Beacon s in-sourced approach deploys utilization managers, care managers and provider network professionals into each local market where Beacon conducts business. This approach facilitates better coordination of care for members with physical, behavioral and social conditions and is designed to support a medical home model. Quantifiable results prove that this approach improves the lives of individuals and their families and helps plans to better integrate behavioral health with medical health. Humana CareSource TM has delegated behavioral health related functions to Beacon. These include: 1) Contracting and credentialing of behavioral health providers 2) Utilization review and medical management for behavioral health services 3) Administrative appeals (Humana CareSource TM will process clinical appeals) 4) Claims processing and payment; 5) Member rights and responsibilities; 6) Quality management and improvement; 7) Member services, including management of the Behavioral Health Hotline 8) Referral and triage; 9) Ensuring service accessibility and availability 10) Treatment record compliance; and 11) Care management. BEACON HEALTH STRATEGIES Provider Manual 3

8 1.2 Beacon/ Humana CareSource TM Behavioral Health Program The Humana CareSource TM behavioral health program provides members with access to a full continuum of behavioral health services through our network of contracted providers. The primary goal of the program is to provide medically necessary care in the most clinically appropriate and costeffective therapeutic settings. By ensuring that all Plan members receive timely access to clinically appropriate behavioral health care services, Humana CareSource TM and Beacon believe that quality clinical services can achieve improved outcomes for our members. 1.3 Network Operations Beacon s Network Operations Department, with Provider Relations, is responsible for procurement and administrative management of Beacon s behavioral health provider network. Beacon s role includes contracting, credentialing and provider relations functions for all behavioral health contracts. Representatives are easily reached by via or by phone between 8:30 AM and 6:00 PM eastern standard time (EST) Monday through Thursday, and 8:30 AM to 5:00 PM EST on Fridays at Contracting and Maintaining Network Participation A participating provider is an individual practitioner, private group practice, licensed outpatient agency, or facility that has been credentialed by Beacon and has signed a Provider Services Agreement (PSA) with Beacon and Humana. Participating providers agree to provide covered behavioral health and/or substance use services to members, to accept reimbursement according to the rates set forth in the fee schedule attached to each provider s PSA, and to adhere to all other terms in the PSA including this provider manual. Participating providers who maintain approved credentialing status remain active network participants unless the PSA is terminated in accordance with the terms and conditions set forth therein. In cases where a provider is terminated, providers may notify the member of their termination. Beacon will also always notify members when their provider has been terminated and work to transition BEACON HEALTH STRATEGIES Provider Manual 4

9 members to another participating provider to avoid unnecessary disruption of care. 1.5 About This Provider Manual This Behavioral Health Provider Policy and Procedure Manual (hereinafter, the Manual ) is a legal document incorporated by reference as part of each provider s Beacon/Humana Provider Services Agreement. The Manual serves as an administrative guide outlining Beacon s policies and procedures governing network participation, service provision, claims submission, quality management and improvement requirements, in Chapters 2-3. Detailed information regarding clinical processes, including authorizations, utilization review, care management, reconsiderations and appeals are found in Chapters 4 and 5. Chapter 6 covers billing transactions. Beacon s level-of-care criteria (LOCC) are accessible through eservices or by calling Beacon. Additional information is provided in the following appendix listed below: Appendix A: Links to Clinical and Quality Forms The Manual is posted on both Humana CareSource TM and Beacon s websites and on Beacon s eservices; only the version on eservices includes Beacon s LOCC. Providers may also request a printed copy of the Manual by calling Humana CareSource TM at or Beacon at Updates to the Manual as permitted by the Provider Services Agreement will be posted on the Humana CareSource TM and Beacon websites, and notification may also be sent by postal mail and/or electronic mail. Beacon provides notification to network providers at least 60 days prior to the effective date of any policy or procedural change that impacts providers, such as modification in payment or covered services. Beacon provides 60 day s notice unless the change is mandated sooner by state or federal requirements. 1.6 Transactions and Communications with Beacon Beacon s website, contains answers to frequently asked questions, Beacon's clinical practice guidelines, clinical articles, links to numerous clinical resources, and important news for providers. As described below, eservices and EDI are also accessed through the website. BEACON HEALTH STRATEGIES Provider Manual 5

10 ELECTRONIC MEDIA To streamline providers business interactions with Beacon, we offer three provider tools: a) eservices On eservices, Beacon s secure web portal supports all provider transactions, while saving providers time, postage expense, billing fees, and reducing paper waste. eservices is completely free to Beacon providers contracted for Humana CareSource TM and is accessible through twenty four hours a day, seven days a week. Many fields are automatically populated to minimize errors and improve claim approval rates on first submission. Claim status is available within 2 hours of electronic submission, all transactions generate printable confirmation, and transaction history is stored for future reference. Because eservices is a secure site containing member-identifying information, users must register to open an account. There is no limit to the number of users and the designated account administrator at each provider practice and organization, controls which users can access each eservices features. Click here to register for an eservices account; have your practice /organization s NPI and tax identification number available. The first user from a provider organization or practice will be asked to sign and fax the eservices terms of use, and will be designated as the account administrator unless/until another designee is identified by the provider organization. Beacon activates the account administrator s account as soon as the terms of use are received. Subsequent users are activated by the account administrator upon registration. To fully protect member confidentiality and privacy, providers must notify Beacon of a change in account administrator, and when any users leave the practice. The account administrator should be an individual in a management role, with appropriate authority to manage other users in the practice or organization. The provider may reassign the account administrator at any time by ing b) Interactive Voice Recognition Interactive voice recognition (IVR) is available to providers as an alternative to eservices. It provides accurate, up-to-date information by telephone, and is available for selected transactions at In order to maintain compliance with HIPAA and all other federal and state confidentiality/privacy requirements, providers must have their practice or organizational tax identification number (TIN), national provider identifier (NPI), as well as member s full name, Plan ID and date of birth, when verifying eligibility through eservices and through Beacon s IVR. c) Electronic Data Interchange Electronic data interchange (EDI) is available for claim submission and eligibility verification directly by providers to Beacon or via an intermediary. For information about testing and setup for EDI, download Beacon s 837 & 835 companion guides. Beacon accepts standard HIPAA 837 professional and institutional health care claim BEACON HEALTH STRATEGIES Provider Manual 6

12 Beacon encourages providers to communicate with Beacon by addressed to Throughout the year Beacon sends providers alerts related to regulatory requirements, protocol changes, helpful reminders regarding claim submission, etc. In order to receive these notices in the most efficient manner, we strongly encourage you to enter and update addresses and other key contact information for your practice, through eservices. COMMUNICATION OF MEMBER INFORMATION In keeping with HIPAA requirements, providers are reminded that personal health information (PHI) should not be communicated via , other than through Beacon s eservices. PHI may be communicated by telephone or secure fax. It is a HIPAA violation to include any patient identifying information or protected health information in non-secure through the internet. 1.7 Access Standards Humana CareSource TM members may access behavioral health services 24 hours a day, seven days a week by contacting Humana CareSource TM s member services line or by calling the Humana CareSource TM Behavioral Health Hotline at Members do not need a referral to access behavioral health services and authorization is never required for emergency services. Humana CareSource TM and Beacon adhere to State and National Committee for Quality Assurance (NCQA) guidelines for access standards for member appointments. Contracted providers must adhere to the following: TABLE 1-2: APPOINTMENT STANDARDS AND AFTER HOURS ACCESSIBILITY: Type of Care Emergency Care with Crisis Stabilization Urgent Care Post Discharge from Acute Hospitalization Other routine referrals/appointments Appointment Availability Within twenty four (24) hours Within forty eight (48) hours Within 7 days of discharge Within sixty (60) days Access standards for Humana CareSource TM s behavioral health network are established to ensure that members have access to services within sixty (60) miles or a maximum of sixty (60) minutes of their address. In addition, Humana CareSource TM providers must adhere to the following guidelines to ensure members have adequate access to services: BEACON HEALTH STRATEGIES Provider Manual 8

13 Service Availability On-Call Crisis Intervention Outpatient Services Interpreter Services Cultural Competency Hours of Operation: 24-hr on-call services for all members in treatment; and Ensure that all members in treatment are aware of how to contact the treating or covering provider after hours and during provider vacations. Services must be available 24 hours per day, 7 days per week; Outpatient facilities, physicians and practitioners are expected to provide these services during operating hours; and After hours, providers should have a live telephone answering service or an answering machine that specifically directs a member in crisis to a covering physician, agency-affiliated staff, crisis team, or hospital emergency room. Outpatient providers should have services available Monday through Friday from 9 a.m. to 5 p.m. at a minimum; and Evening and/or weekend hours should also be available at least 2 days per week. Under state and federal law, providers are required to provide interpreter services to communicate with individuals with limited English proficiency. Providers must ensure that members have access to medical interpreters, signers and TTY services to facilitate communication when necessary and ensure that clinicians and agency are sensitive to the diverse needs of Humana CareSource TM members. Providers are required to meet these standards, and to notify Beacon if they are temporarily or permanently unable to meet the standards. If a provider fails to provide services within these access standards notice is sent out within one business day informing the member and provider that the waiting time access standard was not met. 1.8 Provider Credentialing & Recredentialing Beacon conducts a rigorous credentialing process for network providers based on Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) guidelines. All providers must be approved for credentialing by Beacon in order to participate in Beacon s behavioral health services network, and must comply with recredentialing standards by submitting requested information within the specified timeframe. Private solo and group practice clinicians are individually credentialed, while facilities are credentialed as organizations; the processes for both are described below. To request credentialing information and an application(s), please BEACON HEALTH STRATEGIES Provider Manual 9

14 TABLE 1-3: CREDENTIALING PROCESS Individual Practitioner Credentialing Beacon individually credentials and recredentials the following categories of clinicians in private solo or group practice settings: Psychiatrists; Psychologists; Master s level therapists, designated by the applicable KY licensing board(s) as independently-licensed providers; Other behavioral healthcare specialists who are master s level or above and who are licensed, certified, or registered by the State of KY and who fall within the scope of eligible provider types by the Credentialing Committee. Organizational Credentialing Beacon credentials and recredentials facilities and licensed outpatient agencies as organizations. Facilities that must be credentialed by Beacon as organizations include: Licensed outpatient clinics and agencies including hospital-based clinics; Freestanding inpatient behavioral health facilities freestanding and within general hospitals; Inpatient behavioral health units at general hospitals; Inpatient detoxification facilities or units; Other outpatient behavioral health and substance abuse services as delineated by the State of KY. INDIVIDUAL PRACTITIONER CREDENTIALING To be credentialed by Beacon, practitioners must be licensed and/or certified in accordance with the State of KY licensure requirements and the license must be in force and in good standing at the time of credentialing or recredentialing. Practitioners must submit a complete practitioner credentialing application with all required attachments. All submitted information is primary-source verified by Beacon Providers are notified of any discrepancies found and any criteria not met, and they have the opportunity to submit additional clarifying information. Discrepancies and/or criteria not met may disqualify the practitioner from network participation. Once the practitioner has been approved for credentialing and has been contracted with Beacon as a solo practitioner, or when a practitioner has been credentialed as a staff member of a contracted practice, Beacon will either notify the solo practitioner or the practice s credentialing contact of the date on which the practitioner may begin to serve members of specified health plans. ORGANIZATIONAL CREDENTIALING In order to be credentialed, facilities must be licensed or certified by the state in which they operate and the license must be in force and in good standing at the time of credentialing or recredentialing. If the facility reports accreditation by The Joint Commission, the Council on Accreditation of Services for Family and Children (COA), or the Council on Accreditation of Rehabilitation Facilities (CARF), such accreditations must be in force and in good standing at the time of the initial credentialing cycle, as well as at the time of each subsequent recredentialing cycle for the facility. If the facility is not accredited by one of these accreditation organizations, Beacon conducts a site visit prior to rendering a credentialing decision. The credentialed facility is responsible for credentialing and overseeing its clinical staff as Beacon does not individually credential facility-based staff. Behavioral health program eligibility criteria include applicable accreditation requirements. Once the facility has been approved for credentialing and has been contracted with Beacon to serve BEACON HEALTH STRATEGIES Provider Manual 10

15 members of one or more health plans, all licensed or certified behavioral health professionals approved by Beacon may treat members in the facility setting, and these practitioners must hold current, nonrestricted licenses in their area of practice. RECREDENTIALING All practitioners and organizational providers are processed via re credentialing within 36 months of the previous credentialing/recredentialing approval date in accordance with State regulations and Beacon s Policies. Practitioners and providers must continue to meet Beacon s established credentialing criteria and quality of care standards for continued participation in Beacon s behavioral health provider network including but not limited to: A. A current license to practice; B. The status of clinical privileges at the hospital designated by the practitioner as the primary admitting facility; C. A valid DEA number, if applicable; D. Board certification, if the practitioner was due to be recertified or become board certified since last credentialed or recredentialed; E. Five (5) year history of professional liability claims that resulted in settlement or judgment paid by or on behalf of the practitioner; and F. A current signed attestation statement by the applicant regarding: 1. The ability to perform the essential functions of the position, with or without accommodation; 2. The lack of current illegal drug use; 3. A history of loss, limitation of privileges or any disciplinary action; and 4. Current malpractice insurance. Prior to making a recredentialing decision, Beacon will also verify information about sanctions or limitations on practitioner from: A. The national practitioner data bank; B. Medicare and Medicaid; C. State boards of practice, as applicable; and D. Other recognized monitoring organizations appropriate to the practitioner s specialty. Failure to comply with recredentialing requirements, including timelines, may result in removal from the network. BEACON HEALTH STRATEGIES Provider Manual 11

16 All practitioners and organizational providers are given thirty (30) days, following the initial adverse decision, to file an appeal with the Credentialing Committee and to submit additional information in support of their appeal. If no appeal is initiated, the decision of the Credentialing Committee shall be implemented, and Beacon s Director of Credentialing and Data reports Beacon s action to the appropriate regulatory bodies, including the National Practitioner Data Bank and the appropriate licensing agencies and authorities, in accordance with local, state, and federal requirements, if it is a reportable situation. If an appeal is initiated, the Credentialing Committee is notified. The practitioner or organizational provider is notified of the date on which the Credentialing Committee will review the appeal, which will be within thirty (30) days of receipt of the appeal request. The practitioner or organizational provider may attend the Credentialing Committee meeting and personally present their case to the Committee on that date and/or may be represented by an attorney or another person of the practitioner or facility/organization s choice. Either Beacon or the provider may elect to engage, at their own expense, a court stenographer to attend the hearing and prepare a transcription. If the other party wishes to obtain a copy of the transcript, that party shall pay one-half the cost of the court stenographer. The Credentialing Committee again reviews the case and makes a decision based on the additional information. Beacon notifies the practitioner or organizational provider of the committee s decision regarding the appeal, including the specific reasons for the decision within ten (10) business days of the meeting. If the practitioner or organizational provider is not satisfied with the first appeal decision, the decision may be appealed a second time to Beacon s Appeals Panel. The procedures for the first level appeal described above, are also applicable to the second level appeal. The appeal shall be completed prior to the implementation of any proposed action(s). The Appeals Panel makes a decision regarding this second and final appeal. The panel may either reaffirm the previous Credentialing Committee decision or overturn it. The Appeals Panel s decision is final. Beacon notifies the practitioner or organizational provider of the decision within ten (10) business days of the Appeals Panel s decision. Results of the final Beacon review are reported to the appropriate regulatory bodies, if required, including the National Practitioner Data Bank and the appropriate licensing agencies and authorities, in accordance with local, state, and federal requirements. BEACON HEALTH STRATEGIES Provider Manual 12

17 1.9 Prohibition on Billing Members Health plan members may not be billed for any covered service or any balance after reimbursement by Beacon except for any applicable co-payment. Further, providers may not charge the Plan members for any services that are not deemed medically necessary upon clinical review or which are administratively denied. It is the provider s responsibility to check benefits prior to beginning treatment of this membership and to follow the procedures set forth in this manual. OUT OF NETWORK PROVIDERS Out of network behavioral health benefits are limited to those covered services that are not available in the existing Humana CareSource TM /Beacon network, emergency services and transition services for members who are currently in treatment with an out of network provider who is either not a part of the network or who is in the process of joining the network. Out of network providers must complete a single case agreement with Beacon (SCA). Out of network providers may provide one evaluation visit for Humana CareSource TM members without an authorization upon completion and return of the signed SCA. After the first visit, services provided must be authorized. Authorization requests for outpatient services can be obtained through Beacon s electronic outpatient request for (eorf) which can be requested by calling Beacon at or on Beacon s website If this process is not followed, Beacon may administratively deny the services and the out of network provider must hold the member harmless. PROVIDER DATABASE Beacon and Humana CareSource TM maintain a database of provider information as reported to us by providers. The accuracy of this database is critical to operations, for such essential functions as: Member referrals Regulatory reporting requirements Network monitoring to ensure member access to a full continuum of services across the entire geographic service area; and Network monitoring to ensure compliance with quality and performance standards including appointment access standards. Provider-reported hours of operation and availability to accept new members are included in Beacon s provider database, along with specialties, licensure, language capabilities, addresses and contact information. This information is visible to members on our website and is the primary information source for us to use when assisting members with referrals. In addition to contractual and regulatory requirements pertaining to appointment access, up-to-date practice information is equally critical to ensuring appropriate referrals to available appointments. The table below lists required notifications. Most of these can be updated via Beacon s eservices portal or by . TABLE 1-4: REQUIRED NOTIFICATIONS Type of Information General Practice Information Change in address or telephone number of any service; Addition or departure of any professional staff; Change in linguistic capability, specialty or program; BEACON HEALTH STRATEGIES Provider Manual 13

18 Discontinuation of any covered service listed in the Behavioral Health Services Agreement; Change in licensure or accreditation of provider or any of its professional staff. Change in licensure or accreditation of provider or any of its professional staff. Change in hours of operation; Is no longer accepting new patients; Is available during limited hours or only in certain settings; Has any other restrictions on treating members; or Is temporarily or permanently unable to meet Beacon standards for appointment access. Change in designated account administrator for the provider s eservices accounts; Merger, change in ownership, or change of tax identification number Adding a site, service or program not previously included in the Behavioral Health Services Agreement, remember to specify: a) Location; and b) Capabilities of the new site, service, or program. ADDING SITES, SERVICES AND PROGRAMS Your contract with Beacon is specific to the sites, rates and services for which you originally specified in your Provider Services Agreement. To add a site, service or program not previously included in your PSA, you should notify Beacon of the location and capabilities of the new site, service or program. Beacon will coordinate with Humana CareSource TM to determine whether the site, service or program meets an identified geographic, cultural/linguistic and/or specialty need in our network. BEACON HEALTH STRATEGIES Provider Manual 14

20 2.1 Members, Benefits and Member-Related Policies Humana CareSource TM covers behavioral health services to members located in Region 3. Under the Plan, the following levels of care are covered, provided that services are medically necessary, delivered by contracted network providers, and that the authorization procedures outlined in this manual are followed. Please refer to your contract with Humana CareSource TM for specific information about procedure and revenue codes and rates for each service. Inpatient mental health Crisis stabilization Emergency room visits Medical detoxification Psychiatric residential treatment facilities (PRTF) Extended care units (ECU- EPSDT Special Service) Residential substance abuse rehabilitation (EPSDT special service- through age 21 only) Substance abuse rehabilitation (for pregnant/post-partum women only) Outpatient mental health services Outpatient and community based substance abuse services for pregnant/postpartum women Electroconvulsive Therapy (ECT) Psychological and neuropsychological testing Community Mental Health Center Services, such as therapeutic rehabilitation, targeted case management etc. Impact Plus services Access to behavioral health treatment is an essential component of a comprehensive health care delivery system. Plan members may access behavioral health services by self-referring to a network provider, by calling Beacon, or by referral through acute or emergency room encounters. Members may also access behavioral health services by referral from their primary care practitioner (PCP); however a PCP referral is never required for behavioral health services. Network providers are expected to coordinate care with a member s primary care and other treating providers whenever possible. ADDITIONAL BENEFIT INFORMATION Benefits do not include payment for behavioral health care services that are not medically necessary. Neither Beacon nor the health plan is responsible for the costs of investigational drugs or devices or the costs of non-healthcare services such as the costs of managing research or the costs of collecting data that is useful for the research project but not necessary for the enrollee s care. Authorization is required for all services except emergency services. Detailed information about authorization procedures is covered in Chapter 4 of this manual. BEACON HEALTH STRATEGIES Provider Manual 16

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